Anamarie P. Berja
CASE 1
CC. is a 68 yo F who is complaining of chest heaviness and shortness of breath while cleaning
the house which is relieved with rest. Symptoms started a few months ago but she did not seek
care because she thought the shortness of breath was a lung problem and sign of getting old.
Symptoms are now occurring more frequently so she is seeking medical advice.
PMH: DM, diet controlled
Breast cancer, s/p mastectomy and hormone therapy
Allergies: NKDA
Medications: multivitamin
SH: denies tobacco, alcohol, or illicit drug use
FH: dad had CABG at age 50, sister diagnosed with CAD at age 60 & has DM & CVA
VS: Ht 5’4”wt: 109 lbs
BP 150/85HR 90
PE: unremarkable
Point of Care testing in the office: Total Cholesterol 250 (nl < 200) HDL 30 (nl > 60)
EKG: no changes consistent with ischemia
CC’s stress test is “+” for inducible ischemia (ie: likelihood of CAD is high). A coronary angiogram
is recommended, but patient has company coming to visit from out of town so wants to wait.
Antianginal therapy is recommended to decrease the patient’s symptoms
1. What is your plan for treating CC’s angina and why? (please include mechanism of
action with your answer
- In treating the angina, this could be relieved through resting/taking sublingual nitrates .
MOA: Organic nitrates relax vascular smooth muscle by their intracellular conversion to
nitrite ions and then to nitric oxide, which activates guanylate cyclase and increases the cells’
cyclic guanosine monophosphate (cGMP). Elevated cGMP ultimately leads to
dephosphorylation of myosin light chain, resulting in vascular smooth muscle relaxation.
(UIC review, Bacon)
2. In addition to the antianginal medication you recommended above, what other
evidence based medications would you consider starting and why?
- Since the ptxt might be experiencing Chronic stable angina pectoris, aside from nitrates,
we could consider Beta-blockers to reverse the effect of tachycardia. (UIC Review,
Bacon)
CC. returns 1 month later for cardiac cath which reveals 3 vessel disease and it is
recommended that she have coronary artery bypass surgery. She is nervous about having
surgery so she wants to think about it and try medical management for now.
She still gets symptoms with exertion every day but has decreased from about 5-6x/day to 2-4
x/day. Symptoms are mostly relieved by rest however he states he uses a SL nitroglycerin
about once a week.
Medication:
Atenolol 100 mg daily (states adherence but c/o severe fatigue)
ASA 162 mg daily
Atorvastatin 40 mg daily
BP: 116/70HR 70
3. What do you recommend for CC to further decrease the episodes of angina she is
having? State drug or drug class and reason for your choice.
- We could consider Calcium channel blockers , Non-dihydropyridines alternative for
BB’s, dilating peripheral and coronary arteries, and to a varying degree depress
myocardial contractility and intra-cardiac conduction. (2011, National Clinical
Guidelines Centre)
CASE 2
JF is a 40 yo Asian male with recently diagnosed dilated cardiomyopathy. Etiology is thought
to be due to a viral illness. He was discharged from the hospital 2 weeks ago and now is in the
Heart Center for his follow-up appointment. He complains of DOE at ½ to 1 block but this is
improved from not even being able to walk across the room. SOB with ADLs if he tries to do
things too fast. He is sleeping on 2 pillows and occasionally gets PND (improved from qhs).
Also complains of fatigue and weakness but no dizziness.
PMH: none
SH: no tob/illicit ETOH few beers while watching football games
Meds: Lisinopril 10 mg daily, Furosemide 60 mg daily
PE: HR 95 BP 105/70 Ht 5’10” Wt 190 lbs
HEENT: no JVD, decreased carotid upstrokes
Lungs: clear to auscultation and percussion
CV: normal S1, S2, no murmurs S3 or S4
Abdomen: unremarkable
Ext: 1+ LE edema to just above ankle, improved from 3+ on admission
Echo: EF 25%
Assessment: Stage C heart failure, NYHA FC III
1. What is your recommendation for management of patient’s heart failure today?
Provide drug/dose/rationale
-For ptx heart failure we can recommend ACE inhibitors or Angiotensin II receptor blockers.
Tho, the ptxt can continue taking the medication he’s into provided;
Maintenance dose: Dosage should be increased as tolerated
Maximum dose: 40 mg orally once a day
Rationale: ACE inhibitors is atype of drug that widens or dilates blood vessels (vasodilator)
to lower blood pressure, improve blood flow and decrease the heart's workload. Angiotensin
II receptor blockers may be an alternative for people who can't tolerate ACE inhibitors.
The diuretic dose may need to be adjusted to help minimize hypovolemia which may
contribute to hypotension. (https://www.mayoclinic.org/diseases-conditions/dilatedcardiomyopathy/diagnosis-treatment/drc-20353155)
4 months later JF returns to the heart failure clinic after a hospitalization for volume
overload.
Meds on discharge are:
lisinopril 20 mg daily,
metoprolol succinate 200 mg daily,
furosemide 40 mg bid.
Current symptoms: DOE at 1 blocks or 1/2 flight of stairs, showering/shaving, 2 pillow orthopnea,
mild fatigue + positional dizziness which is stable
Vitals: BP 110/70 HR 64 bpmwt 180 pounds
PE: JVP nl, + HJR, lungs clear, 1+ pitting edema in ankles.
BUN/Cr: 35/1.8 K 4.8 (CrCl 63 ml/min)
Repeat Ejection Fraction 25%
For the following interventions, indicate whether you think the intervention is APPROPRIATE
or INAPPROPRIATE (circle) and explain why. Consider each intervention independent of the
other as opposed to a cumulative plan
2. Add eplerenone 25 mg dailyAPPROPRIATEINAPPROPRIATE
APPROPRIATE
Why?
-We could add eplerenone to furosemide to achieve the optimal effect treating excessive fluid
accumulation. (https://www.drugs.com/drug-interactions/eplerenone-with-lasix-997-0-1146676.html)
3. Add BiDil (hydralazine 37.5/ISDN 20 mg ) tidAPPROPRIATEINAPPROPRIATE
INAPPROPRIATE
Why?
-Because although hydroCHLOROthiazide and lisinopril are frequently combined together, their
effects may be additive on lowering your blood pressure. (https://www.drugs.com/druginteractions/hydralazine-plus-with-lisinopril-1254-6835-1476-0.html)
4. Change Lisinopril to Sacubatril/Valsartan 49/51 mg bid
APPROPRIATEINAPPROPRIATE
APPROPRIATE
Why?
-to provide good blood pressure (BP) control without eliciting adverse effects. Both were both
highly effective in controlling BP but valsartan was associated with a significantly reduced risk for
AEs, especially cough. (Clin Ther. 2004 Jun;26(6):855-65.)
5. Add ivabradine 5 mg bidAPPROPRIATEINAPPROPRIATE
INAPPROPRIATE
Why?
-since anti hypertensive drugs are already in the list, & the problems were already addressed , there
is no need to add Ivabradine. Ivabradine treatment carries a substantially higher risk of AF
(https://www.drugs.com/mtm/ivabradine.html)
CASE 3
HC is a 65 yo white female who developed heart failure due to untreated HTN. No CAD per
angiogram results. She was last seen 1 month ago by her PCP when the furosemide dose was
increased from 40 mg daily to 80 mg bid secondary to volume overload. She is in your clinic
for the 1st time. She states her symptoms are back to baseline; walking 2 blocks or 1 flight of
stairs before getting short of breath. She still complains of being tired and weak all the time.
She also gets dizzy when getting up from a chair or out of bed, which is new.
PMH: Heart failure, most recent ejection fraction
30% arthritis
Meds: furosemide 80 mg bid
losartan 50 mg daily
carvedilol 6.25 mg bid
aspirin 81 mg daily
naproxen 375 mg bid
PE:HR 100, BP 110/70, height 5’6 weight 160 lbs ( was 170 last visit),
HEENT: no JVD
Lungs: clear to auscultation and percussion
CV: no S3 or S4
Abdomen: unremarkable
Ext: good color and pulses, no edema
Labs: Na 140 mEq/L, K 5.2 mEq/L (normal 3.6-5.3), BUN 48 mg/dL ( was 16 mg/dL 1 month ago /
nl < 20), SCr 1.6 mg/dL (SCr 1.0 one month ago / nl < 1.2),
MD assessment, NYHA FC II
1. What is your plan for her diuretic?
Decrease furosemide to 40 mg
bid
Decrease furosemide to 40 mg
daily
Cpm with furosemide 80 mg
bid
Rationale?
2. What do you want to do with her ARB today?
3. What do you want to do with her BB today?
4. What other recommendations to you have regarding her medications?
3 months later pt returns to office s/p her 2nd hospitalization for acute decompensated heart
failure. Each episode occurred after going out to dinner with friends. She states after the `1st
admit, all the fluid was gone but this time still has LE edema and DOE with 1 block (baseline
if 4 blocks) and ADLs. Because of this, she has self-increased her diuretic but states no change
in weight or much response in regards to urination.
Meds on discharge from hospitalization
Lisinopril 20 mg daily
Carvedilol 25 mg bid
Furosemide 80 mg bid (160 mg bid last 2 days)
Digoxin 0.25 mg daily
PE: BP 105/70 HR 75 Ht 5’6” wt 180 pounds
HEENT: + JVD
Lungs: + crackles at bases bilaterally
CV: no S3 or S4
Abdomen: + HJR
Ext 2+ edema to shins
Pertinent labs on discharge last week: BUN/Cr 30 (nl < 20) /1.4 (nl < 1.2) K 4.5 (Cr Cl 48
ml/min) EF report from hospitalization = 25%
MD assessment: HFr-EF, stage C, FC III with signs of volume overload
5. Provide a recommendation for managing her fluid overload (drug and why)
6. The doctor asks you about her digoxin since this is a new medication. Which response is
most appropriate? Provide rationale for your answer
Continue digoxin as is
D/c digoxin
Decrease digoxin to 0.125 mg/day
Rationale:
2 months later she is at the office for a follow up visit. Despite being on target doses and
improvement in her diet (more home cooking, less salt and fluid), she still got hospitalized for
fluid overload and has been diagnosed with atrial fibrillation. Overall her edema is much
improved and she is now NYHA FC II. Meds updated after discharge as below.
Meds:
Lisinopril 20 mg daily
Bumetanide 2 mg bid
Eplerenone 50 mg daily
Vitals: BP 110/70 HR 85
No JVD
Lungs: clear
Abdomen: benign
LE edema 1+ to mid shin
Carvedilol 25 mg bid
Digoxin 0.125 mg daily
Rivaroxaban 15 mg daily
Labs: BUN/Cr 35/1.8 (CrCL 45
ml/min) K 4.8, EF = 25%
7. The doctor as asking about sacubitril/valsartan and/or ivabradine. Please provide
your recommendation about each of these drugs
If recommending the drug, provide dosing instructions.
Sacubatril/valsartan
Ivabradine
Conversion Table for Common Labs1,2,3
Conventional Units
Electrolytes
SI Units
Conversion
Factor
Na
135-145 mmol/L
135-145 mmol/L
1
K (Full-term – adults)
3.5-5.3 mmol/L
3.5-5.3 mmol/L
1
K (Premature infants)
Cl
4.5-7.2 mmol/L
4.5 0 7.2 mmol/L
1
98-108 mmol/L
98-108 mmol/L
1
CO2
24-32 mmol/L
24-32 mmol/L
1
AGAP
3 - 11 mmol/L
3 - 11 mmol/L
1
Ca
8.6 - 10.6 mg/dL
2.15 - 2.65 mmol/L
0.25
Mg
1.8-2.4 mg/dL
0.7 - 1.0 mmol/L
0.411
Phos (10 years – adult)
3 - 4.5 mg/dL
0.97 - 1.45 mmol/L
0.323
Phos (< 10 years of age)
4.5 – 6.5 mg/dL
1.45 – 2.1 mmol/L
0.323
6 -20 mg/dL
2.1 - 7.1 mmol/L
0.357
0.4 - 1.2 mg/dL
12 -20
35 -106 µmol/L
88.4
75 - 125 mL/min/1.73m2
1.24 - 2.08 mL/s/1.73m2
0.0167
Estimated CrCl (1 day old)
5 – 50 mL/min/1.73m2
0.08 - 0.83 mL/s/1.73m2
0.0167
Estimated CrCl (6 days old)
15 -90 mL/min/1.73m2
0.25 -1.5 mL/min/1.73m2
0.0167
Estimated GFR
> 60 mL/min/1.73 m2
> 60 mL/min/1.73 m2
1
Glucose
Glucose (POCT)
65 - 110 mg/dL
3.6 - 6.1 mmol/L
0.0555
65 - 110 mg/dL
3.6 - 6.1 mmol/L
0.0555
45 - 150 mg/dL
0.5 - 1.7 mmol/L
0.0113
Total bilirubin
Direct bilirubin
0 - 1.2 mg/dL
0 - 20.5 µmol/L
17.104
0 - 0.2 mg/dL
0 - 3.4 µmol/L
17.104
Alkaline phosphatases
40 - 125 u/L
40 - 125 u/L
1
AST
10-40 u/L
10-40 u/L
1
ALT
10-50 u/L
10-50 u/L
1
Protein (> infant – adult)
6 – 8 g/dL
60 – 80 g/L
10
Protein (newborn -infant)
4.5 – 6.5 g/dL
45 – 65 g/L
10
3.5 – 5 g/dL
35 – 50 g/L
10
2.6 – 3.6 g/dL
26 – 36 g/L
10
4.5 – 10.2 x 103/µL
4.5 10.2 x 109/L
1
Hemoglobin
11 – 15 g/dL
110 – 150 g/L
10
Hematocrit
33 – 45%
0.33 – 0.45
0.01
150 – 330 x 103/µL
150 – 330 x 109/L
1
Renal/Metabolic Tests
BUN
Creatinine
BUN/Creat Ratio
Estimated Creatinine
Clearance (Infant – adult)
Lipids
Triglycerides
Liver Function Test
Albumin (infant - adult)
Albumin (newborn)
Complete Blood Count (CBC)
WBC
Platelets
1Scully et al. Normal reference
Laboratory values. NEJM
reference ranges (3rd ed).
Washington, DC: AACC Press. 3Hay et al. (2000). Current pediatric
treatment (15th ed). New York: Lange Medical Books/McGraw Hill.
1998;339:1063-72. 2Soldin et al. (1999). Pediatric
diagnosis and
Digoxin Dosing Nomogram